Painful conditions having the origin within the musculoskeletal system is a common cause for people to seek medical care. Between 20-40% of all visits to the primal care in Sweden are coupled to pain from the musculoskeletal system. Muscle pain and impaired muscle function can be caused by muscles being repetitively overused and/or via heavy load. Skeletal muscle is a dynamic tissue which can undergo changes in order to fulfill what is best for optimal function. However, if the load is too heavy, morphological changes including necrosis, as well as pain can occur. The extension of the skeletal muscle is the tendon. Tendinopathy refers to illness and pain of the tendon. The peritendinous tissue is of importance in the features related to tendon pain. Common tendons/origins being afflicted by tendinopathy/pain are the Achilles tendon and the extensor origin at the elbow region.    Tumor necrosis factor alpha (TNF-alpha) is a cytokine that is involved in several biological processes. It is well-known for its involvement in the immune system and is an important target for inflammatory disorders such as rheumatoid arthritis. It is not known to what extent the TNF-alpha system is involved in the process of muscle inflammation and damage due to overuse.    Studies were conducted on rabbit and human tissue, tissues that either had undergone an excessive loading activity or tissue that was removed with surgery due to painful conditions. The tissues were evaluated via staining for morphology, in situ hybridization and immunofluorescence.    Unilateral experimental overuse of rabbit muscle (soleus muscle) led to morphological changes in the soleus muscle tissue bilaterally. The longer the experiment extended, the more was the tissue affected. This included infiltration of white blood cells in the tissue (myositis) and abnormal muscle fiber appearances. TNF-alpha mRNA was seen in white blood cells, in muscle fibers interpreted to be in a reparative stage and in white blood cells that had infiltrated into necrotic muscle fibers.  There was an upregulation in expressions of TNF receptor type 1 (TNFR1) and TNF receptor type 2 (TNFR2) in muscles that were markedly overused, with expressions in white blood cells, fibroblasts, blood vessel walls and muscle fibers. Immunoreactions for the receptors were seen in nerve fascicles of markedly overused muscles but only occasionally in normal muscles. The upregulations were seen for both experimental and contralateral sides. Overall the two receptors showed somewhat different expression patterns. Tendinopathy is associated with an increase in blood flow and infiltration of white blood cells in the tissue adjacent to the tendon. It is called the peritendinous tissue and is also richly innervated. The white blood cells and the blood vessels walls in this tissue were showing immunoreaction for TNFR1 and TNFR2. Two types of nerve fascicles were found in this tissue, one normally appearing when staining for nerve markers and one type with signs of axonal loss. The latter had clearly strong immunoreactions for TNFR1 and TNFR2.    The findings suggest that the TNF-alpha system is involved in both myopathies occurring due to overuse and in features in the peritendinous tissue in the tendinopathy situation. TNF-alpha and its receptors seem to be involved in degeneration but also in regeneration and healing of the tissue. The findings also suggest that TNF-alpha has effects on nerves showing axonal loss. The changes in the TNF-alpha system were seen both on the experimental side and contralaterally. / Smärta och funktionsbortfall från rörelseapparaten är vanligt förekommande. Mellan 20-40% av alla besök i primärvården är kopplade till smärta från rörelseapparaten. Det är också en vanlig orsak till sjukfrånvaro. Överansträngning inklusive repetitivt enformigt muskelarbete kan leda till muskelsmärta och bristande muskelfunktion (ex nedsatt styrka och uthållighet, inskränkt rörlighet). Muskelvävnad är en dynamisk vävnad som kan ändras utefter vilka påfrestningar den utsätts för och därigenom vilka behov den ställs inför. Men om belastningen blir för hård, alternativt återhämtningen blir för kort, kan negativa förändringar i vävnadsstrukturen uppstå, inklusive celldöd och vävnadsskada. Förlängningen av muskeln är senan. Senan är den vävnad som förbinder muskeln med skelettet. Tendinopati innefattar smärtsamma sjukdomstillstånd i senan. När sjukdom i en sena uppstår, exempelvis en smärtande hälsena, har man sett att den lösa bindväven som omger senan är av betydelse. Den genomgår morfologiska förändringar och man tror att det är den som är med och bidrar till smärtan vid tillståndet. Akillessenan och ”tennis-armbåge” är vanliga ställen för tendinopati. Akillessenan förbinder den trehövdade vadmuskeln med hälbenet. Tennis-armbåge omfattar ett område för flera musklers ursprung vid armbågen. Dessa muskler ansvarar framför allt för att sträcka i handleden. TNF-alfa är en signalsubstans som är involverad i flertalet biologiska processer. Den är känd för sin del i immunförsvaret och den är ett viktigt mål för behandling av autoimmuna sjukdomar som exempelvis reumatoid artrit. Det är inte känt om TNF-alfa är inblandad i processen som uppstår vid muskelinflammation/muskelskada efter kraftig överansträngning. TNF-alfa har flera receptorer, i det här arbetet har utbredning av TNFR1 och TNFR2 analyserats. Studier har utförts på djur (kaniner) och människa. Kaniner har genomgått ett träningsexperiment, där de utsatts för repetitiva muskelkontraktioner som lett till överansträngningsskador och muskelinflammation. Den muskel som studerats är soleus-muskeln, en del i den trehövdade vadmuskeln. Vävnadsprover har tagits från patienter med smärta i Akillessenan eller tennisarmbåge. Vävnadsproverna från kanin och människa har analyserats med färgningar för morfologi, immunohistokemi för detektering av TNF-alfa och dess receptorer samt för in situ hybridisering för detektion av mRNA i TNF-alfa systemet. Parallellt med färgningar för faktorerna i TNF-alfa systemet har uttryck för andra faktorer studerats. Ensidig överbelastning hos kaniner ledde till samma morfologiska förändringar på båda sidor, det vill säga även i muskeln i det ben som inte hade genomgått träningsexperimentet. Ju längre experimentet pågick, desto större blev de morfologiska förändringarna. TNF-alfa sågs i vita blodkroppar, TNF-alfa mRNA sågs även i förändrade muskelfibrer. Resultatet av parallella dubbelfärgningar tolkades som att dessa muskelfibrer antingen var i en regenererande process eller i en destruktiv process. TNFR1 och TNFR2 uttrycktes i större utsträckning ju längre experimentet pågick och ju mer muskelvävnaden var påverkad av inflammation. TNF receptorer sågs i vita blodkroppar, fibroblaster, muskelfibrer och nervstrukturer hos experimentdjuren. Det såg lika ut på båda sidor, inklusive det ben som inte ingått i experimentet. De två receptorerna skilde sig åt i uttryck. Vävnad från patienter med smärtande senor/smärta vid muskelursprungs-region genomgick också färgningar för faktorer i TNF-alfa systemet. Man kunde se att den lösa bindväven runt senan (den peritendinösa vävnaden) innehöll mycket blodkärl och nerver. De nerver som sågs i denna vävnad var av två typer, en som såg normal ut och en typ som uppvisade tecken på förlust av axoner. Den senare varianten hade en tydlig uppreglering av båda TNF receptorerna. Dessa resultat tyder på att TNF-alfa systemet är involverat i muskelsjukdomar som rör muskelinflammation till följd av kraftig överansträngning och i processerna i bindväven vid smärtande senor. TNF-alfa och dess receptorer verkar vara inblandade i både nedbrytning och uppbyggnad av muskelvävnad, samt påverka nerver som visar tecken på förlust av axoner. Förändringarna i TNF-alfa systemet sågs både på experimentsidan och kontralateralt.

Rheumatic diseases are common, usually chronic, painful and to some extent invalidating medical conditions. Understanding of the disease pathogenesis is still very fragmentary. Hyperreactivity of the immune system and defect of autotolerance are probably contributed by local factors, which helps to explain, why some joints/muscles are more affected than others. All this results from a complex net of interactions between immune cells, synovial fibroblasts, chondrocytes, osteocytes, myocytes and other cells. In the submitted PhD thesis I have focused on three groups of molecules: regulatory RNAs, S100 proteins and autoantibodies. In the theoretical part, I sum up the current knowledge on their biogenesis, function and the role in rheumatology. In the investigative part, I present six original publications and one review on the role of those molecules in development of rheumatoid arthritis (RA) and idiopathic inflammatory myositis (IIM). One of the main studies was focused on expression of PIWI-interacting RNAs (piRNAs) in RA synovial fibroblasts (SF). piRNAs are small regulatory RNAs which in complex with PIWIL proteins regulate gene expression and silence transpozoms. piRNA expression was considered to be limited to germline and cancer cells. We have found 267 PIWI-interacting RNAs to be expressed...

Rheumatic diseases are common, usually chronic, painful and to some extent invalidating medical conditions. Understanding of the disease pathogenesis is still very fragmentary. Hyperreactivity of the immune system and defect of autotolerance are probably contributed by local factors, which helps to explain, why some joints/muscles are more affected than others. All this results from a complex net of interactions between immune cells, synovial fibroblasts, chondrocytes, osteocytes, myocytes and other cells. In the submitted PhD thesis I have focused on three groups of molecules: regulatory RNAs, S100 proteins and autoantibodies. In the theoretical part, I sum up the current knowledge on their biogenesis, function and the role in rheumatology. In the investigative part, I present six original publications and one review on the role of those molecules in development of rheumatoid arthritis (RA) and idiopathic inflammatory myositis (IIM). One of the main studies was focused on expression of PIWI-interacting RNAs (piRNAs) in RA synovial fibroblasts (SF). piRNAs are small regulatory RNAs which in complex with PIWIL proteins regulate gene expression and silence transpozoms. piRNA expression was considered to be limited to germline and cancer cells. We have found 267 PIWI-interacting RNAs to be expressed...

Idiopathische Myositiden stellen die größte Gruppe der erworbenen Myopathien im Erwachsenenalter dar. Die Pathogenese dieser Erkrankungen ist sehr heterogen und nicht in allen Einzelheiten geklärt. Das Auftreten von mitochondrialen Veränderungen und mtDNADeletionen in idiopathischen Myositiden und deren pathophysiologische Bedeutung ist in der Literatur ein kontrovers diskutiertes Thema. Nach der Präsentation des bekannten Wissens über diese Erkrankungen wird in vorliegender Arbeit dieses Thema anhand lichtmikroskopischer Methoden unter Anwendung histologischer Spezialmethoden an Muskelbiopsien von 98 Patienten untersucht. Ziel der Arbeit ist es, mit verschiedenen histologischen Färbemethoden Hinweise für Mitochondrien-Alterationen und feinstrukturelle Charakteristika von primären Mitochondrialen Myopathien in idiopathischen Myositiden zu detektieren. Ein besonderer Schwerpunkt liegt auf der Anwendung einer neuen immunhistochemischen Methode unter Anwendung eines monoklonalen antimitochondrialen Antikörpers. Es wird der Fall eines Mädchens mit muskeldystrophischer Symptomatik dargestellt, dessen Muskelbiopsie im Alter von 7 Jahren die myohistologische Diagnose einer juvenilen Dermatomyositis und Hinweise auf eine mitochondriale Dysfunktion ergab. Die Ergebnisse der immunhistochemischen Methode korrelieren gut mit anderen bekannten mitochondrialen Färbungen, sind sensitiver und stellen möglicherweise eine gute Ergänzung zu den bekannten mitochondrialen Markern und Färbungen dar. Die beobachteten mitochondrialen Dysfunktionen sprechen für die gestörte Mitochondrienfunktion und eine früh im Krankheitsverlauf, am ehesten sekundäre, Beteiligung der Mitochondrien im Krankheitsprozess dieser primär nicht mitochondrialen Erkrankungen:INHALTSVERZEICHNIS ............................................................................................. I Abkürzungsverzeichnis .......................................................................................................................................iii 1 EINLEITUNG....................................................................................................... 1 1.1 Einführung ...................................................................................................................................................... 1 1.2 Aufbau und Funktion der Skelettmuskulatur............................................................................................... 1 1.3 Die Mitochondrien.......................................................................................................................................... 6 1.4 Erkrankungen der Skelettmuskulatur......................................................................................................... 11 1.4.1 Diagnostik der Skelettmuskelerkrankungen............................................................................................. 11 1.4.2 Entzündliche Muskelerkrankungen.......................................................................................................... 13 1.4.2.1 Polymyositis.................................................................................................................................... 15 1.4.2.2 Dermatomyositis .............................................................................................................................. 18 1.4.2.3 Einschlusskörpermyositis................................................................................................................ 21 1.4.3 Mitochondriale Myopathien..................................................................................................................... 23 1.5 Die Muskelbiopsie......................................................................................................................................... 26 1.6 Die Lichtmikroskopie der Skelettmuskulatur ............................................................................................. 28 1.6.1. Die Enzymhistochemie ........................................................................................................................... 28 1.6.2. Grundlagen der Immunhistochemie ........................................................................................................ 31 1.7 Die Elektronenmikroskopie .......................................................................................................................... 35 2 MATERIAL UND METHODEN .......................................................................... 36 2.1 Patienten........................................................................................................................................................ 36 2.1.1 Das Patientenkollektiv ............................................................................................................................. 36 2.1.2 Besonderer Fall einer Patientin mit juveniler Dermatomyositis............................................................... 38 2.2 Methoden....................................................................................................................................................... 44 2.2.1 Die Lichtmikroskopie .............................................................................................................................. 44 2.2.1.1 Enzymhistochemie ........................................................................................................................... 46 2.2.1.2 Immunhistochemie ........................................................................................................................... 49 2.2.2 Die Elektronenmikroskopie ..................................................................................................................... 54 2.3 Statistische Methoden .................................................................................................................................. 54 3 ERGEBNISSE ....................................................................................................... 56 3.1 Ergebnisse der Lichtmikroskopie................................................................................................................ 56 3.1.1 Ergebnisse der Enzymhistochemie........................................................................................................... 56 3.1.2 Ergebnisse der Immunhistochemie .......................................................................................................... 62 3.1.3 Korrelation der Ergebnisse der Enzymhistochemie und Immunhistochemie ........................................... 70 Inhaltsverzeichnis ii 3.2 Ergebnisse der Elektronenmikroskopie....................................................................................................... 73 4 DISKUSSION .................................................................................................... 76 4. 1 Lichtmikroskopie......................................................................................................................................... 76 4.1.1 Enzymhistochemie .................................................................................................................................. 76 4.1.1.1 Cytochrom-c-Oxidase ...................................................................................................................... 76 4.1.1.2 NADH............................................................................................................................................. 80 4.1.1.3 SDH ................................................................................................................................................ 80 4.1.1.4. Engel .............................................................................................................................................. 81 4.1.2 Immunhistochemie.................................................................................................................................. 84 4.2 Elektronenmikroskopie ................................................................................................................................ 89 4.3 Besonderer Fall einer Patientin mit juveniler Dermatomyositis ............................................................... 90 4.4 Effekte des Alterns auf die Mitochondrien und deren klinische Bedeutung ............................................ 93 4.5 Die Rolle der Mitochondrien in der Pathogenese der entzündlichen Muskelerkrankungen .................. 94 5 ZUSAMMENFASSUNG..................................................................................... 98 6 QUELLENANGABEN...................................................................................... 102 6.1 Literaturverzeichnis........................................................................................................................... 102 6.2 Abbildungsverzeichnis ............................................................................................................................... 109 6.3 Tabellenverzeichnis .................................................................................................................................... 110 7 DANKSAGUNG................................................................................................... 111 8 LEBENSLAUF..................................................................................................... 112 9 ERKLÄRUNG ÜBER DIE EIGENSTÄNDIGE ABFASSUNG DER ARBEIT ... 113

Inclusion body myositis and Alzheimer's disease are age-related disorders characterized in part by the appearance of intracellular lesions composed of filamentous aggregates of the microtubule-associated protein tau. Abnormal tau phosphorylation accompanies tau aggregation and may be an upstream pathological event in both diseases. Enzymes implicated in tau hyperphosphorylation in Alzheimer's disease include members of the casein kinase 1 family of phosphotransferases, a group of structurally related protein kinases that frequently function in tandem with the ubiquitin modification system. To determine whether casein kinase 1 isoforms associate with degenerating muscle fibers of inclusion body myositis, muscle biopsy sections isolated from sporadic disease cases were subjected to double-label fluorescence immunohistochemistry using selective anti-casein kinase 1 and anti-phospho-tau antibodies. Results showed that the alpha isoform of casein kinase 1, but not the delta or epsilon isoforms, stained degenerating muscle fibers in all eight inclusion body myositis cases examined. Staining was almost exclusively localized to phospho-tau-bearing inclusions. These findings, which extend the molecular similarities between inclusion body myositis muscle and Alzheimer's disease brain, implicate casein kinase 1 alpha as one of the phosphotransferases potentially involved in tau hyperphosphorylation.

京都大学 / 0048 / 新制・論文博士 / 博士(医学) / 乙第13030号 / 論医博第2112号 / 新制||医||1016(附属図書館) / 32988 / (主査)教授 三森 経世, 教授 松田 秀一, 教授 戸口田 淳也 / 学位規則第4条第2項該当 / Doctor of Medical Science / Kyoto University / DFAM

Yes / Objectives: To assess the test-retest variability of both diffusion parameters and fat fraction (FF) estimates in normal muscle, and to assess differences in normal values between muscles in the thigh. Methods: 29 healthy volunteers (mean age 37 years, range 20-60 years, 17/29 males) completed the study. Magnetic resonance images of the mid-thigh were acquired using a stimulated echo acquisition mode-echoplanar imaging (STEAM-EPI) imaging sequence, to assess diffusion, and 2-point Dixon imaging, to assess FF. Imaging was repeated in 19 participants after a 30 min interval in order to assess test-retest variability of the measurements. Results: Intraclass correlation coefficients (ICCs) for test-retest variability were 0.99 [95% confidence interval, (CI): 0.98, 1] for FF, 0.94 (95% CI: 0.84, 0.97) for mean diffusivity and 0.89 (95% CI: 0.74, 0.96) for fractional anisotropy (FA). FF was higher in the hamstrings than the quadriceps by a mean difference of 1.81% (95% CI:1.63, 2.00)%, p < 0.001. Mean diffusivity was significantly lower in the hamstrings than the quadriceps (0.26 (0.13, 0.39) x10-3 mm2s-1, p < 0.001) whereas fractional anisotropy was significantly higher in the hamstrings relative to the quadriceps with a mean difference of 0.063 (0.05, 0.07), p < 0.001. Conclusions: This study has shown excellent test-retest, variability in MR-based FF and diffusion measurements and demonstrated significant differences in these measures between hamstrings and quadriceps in the healthy thigh. Advances in knowledge: Test-retest variability is excellent for STEAM-EPI diffusion and 2-point Dixon-based FF measurements in the healthy muscle. Inter- and intraobserver variability were excellent for region of interest placement for STEAM-EPI diffusion and 2-point Dixon-based FF measurements in the healthy muscle. There are significant differences in FF and diffusion measurements between the hamstrings and quadriceps in the normal muscle. / ICA-CL-2016-02-017/DH_/Department of Health/United Kingdom; NIHR

PART I: MARKERS OF INFLAMMATION IN DELAYED MUSCLE SORENESS Fifty-five untrained males were assigned to an experimental (E) or a control group (C), to re-examine the concept that DMS represents an acute inflammatory response. Subjects were assigned to receive either Indocin (Id; 100 mg per day) for 2 days prior to the treatment and a placebo (P) for 2 days after (Id-P); or the reverse combination (P-Id); or Id for- 4 days (Id-Id); or placebo (P-P). On the treatment day, to induce DMS, E subjects performed 30 min of bench-stepping with one leg leading throughout; C subjects rested for 30 min. Immediately before and after stepping/resting, all subjects used their right and left leg to perform 19 maximal and 15 submaximal repetitions on the Cybex II. Blood samples were collected -5 min before, immediately after bench stepping (0 h), 2 h after and 24, 48 and 72 h, to evaluate WBC. DMS was also monitored 0, 24, 48 and 72 h. All E subjects experienced a significant amount of DMS (p<.01) which peaked at 48 h after exercise (E=7.58 ± .79 vs 0 for C, X±SEM); however, no significant differences in soreness perception were observed between drug and placebo groups. Total WBC count ( cells/mm³ ) was significantly greater at 0 h (8,340±380) than at -5 min (6,699±365) for both E and C; this increase was most likely a response to Cybex exercise. At 2 h there was a significant increase in total WBC count for E ( 9,603±389) and no change for C ( 8,336±273}. Neutrophils increased significantly at 2 h for E only (6,428±375 vs 4,988±261 for C}. Bench-stepping leads to increases in DMS and increases in WBC count, particularly in neutrophils, 2 h after stepping; this data suggests that inflammation is involved in DMS. PART II: EFFECT OF AN ASPIRIN-LIKE DRUG ON PERCEIVED EXERTION DURING BENCH STEPPING The object of this study was to determine whether perceived exertion (RPE) for the limb performing predominantly positive work was significantly greater than for the limb performing predominantly negative work, during 30 min of bench stepping. A second objective was to determine the effects of indomethacin (Id) on RPE. Thirty-nine males were randomly assigned to a drug (Id) or placebo (P) group and administered 150 mg indomechacin or placebo, beginning 36 h prior to stepping. Results indicated no significant differences between RPE for "concentric" and "eccentric" limbs of the P group inspite of the fact that the metabolic demand of the "concentric" limb was much greater. Indomethacin did not significantly alter RPE during stepping however, when RPE scores were totaled over the entire bench stepping period, the Id condition was associated with a greater (p < .01) psychological cost for the "concentric" leg effort as compared to P; this indicated that indomethacin might alter effort sense related to concentric contractions. / Ph. D.

A miosite por corpos de inclusão (inclusion body myositis - IBM), na sua forma esporádica, é considerada a miopatia adquirida mais comum após os 50 anos de idade. Embora seja incluída no grupo das miopatias inflamatórias, estudos recentes mostram um processo particular de degeneração muscular caracterizado por deposição anormal de agregados de proteínas nas fibras musculares e funcionamento anormal dos principais sistemas de degradação proteica. O objetivo deste estudo foi o de avaliar os aspectos clínicos, histológicos e imunoistoquímicos de pacientes com IBM. Avaliamos 18 casos com diagnóstico de IBM de dois dos principais centros de doenças neuromusculares do Brasil (25 biópsias musculares). Na tentativa de diferenciar os casos de IBM das outras miopatias inflamatórias, determinamos o padrão de expressão tecidual da p-tau (p62), alfa-sinucleína e TDP-43. Também foi avaliada a função lisossomal através da reação da fosfatase ácida (marcação da atividade lisossomal global) e determinação da marcação para LC3B (marcador de autofagia). Foi observado que a IBM predominou no sexo masculino (61% dos casos), da cor branca, com início das manifestações clínicas ao redor dos 59 anos de idade e os sintomas mais frequentes foram fraqueza muscular, instabilidade postural com quedas da própria altura, disfagia e perda ponderal, podendo ainda apresentar dispneia. O diagnóstico demorou em média 7,4 anos após o início dos sintomas e frequentemente esteve associada às seguintes comorbidades: hipertensão arterial sistêmica, diabetes mellitus tipo 2, osteopenia / osteoporose, dislipidemia e hiperuricemia / gota. O padrão de comprometimento muscular na IBM foi caracterizado por tetraparesia de predomínio proximal em membros inferiores e distal em membros superiores. Os valores séricos da creatinofosfoquinase em pelo menos uma das medições foram elevados em todos os pacientes, porém sem ultrapassar 10 vezes o limite superior da normalidade. O uso de imunossupressão não se mostrou eficaz nos pacientes com IBM. Os achados histológicos na IBM incluíram alterações distróficas variáveis com a presença de inflamação endomisial, assim como a ocorrência de vacúolos marginados, além da elevada frequência de alterações mitocondriais. Outros achados histológicos musculares característicos na IBM foram o aumento da atividade lisossomal (aumento global da marcação para fosfatase ácida), a presença de marcação positiva para beta-amilóide (marcação intra-vacuolar pelo vermelho-Congo), o aumento na degradação muscular (relacionada com ativação de LC3B, p-tau, e p62/SQSTM1) e a degeneração muscular (marcação para anti-phospo TDP-43 e para ?-sinucleína). Tais alterações apresentaram alta sensibilidade e especificidade. Sugerimos que a redução do critério de idade do início dos sintomas de mais de 45 anos para mais de 35 anos aumentaria a sensibilidade diagnóstica para os casos com IBM deste estudo de 83% para 100%. Com este estudo, foi possível caracterizar clínica e histológicamente pacientes com IBM em nosso meio, e fornecer indícios do benefício do uso de marcadores de degeneração e autofagia para o diagnóstico e para a determinação de vias ou sistemas celulares envolvidos na patogênese da doença / Sporadic inclusion body myositis (sIBM) is considered the most common acquired myopathy affecting adults aged over 50 years. Although included in the group of inflammatory myopathies, recent studies show a particular process of muscle degeneration characterized by abnormal deposit of protein aggregates in muscle fibers and abnormal operation of the main protein degradation systems. The aim of this study was to evaluate the clinical, histological and immunohistochemical patients with IBM. We evaluated 18 cases with IBM diagnostic of two of the main centers of neuromuscular diseases in Brazil (25 muscle biopsies). In an attempt to differentiate the IBM cases of other inflammatory myopathies, we determined the pattern of tissue expression of p-tau (p62), alfa-synuclein and TDP-43. Also evaluated the lysosomal function by acid phosphatase reaction (marking global lysosomal activity) and determining the markup for LC3B (autophagy marker). It was observed that IBM was predominant in males (61% of cases), white colored, with onset of clinical manifestations around 59 years old and the most common symptoms are muscle weakness, postural instability with high falls, dysphagia and weight loss, and may also present dyspnea. The diagnosis took an average of 7.4 years after the onset of symptoms and was often associated with the following comorbidities: hypertension, type 2 diabetes mellitus, osteopenia / osteoporosis, dyslipidemia and hyperuricemia / gout. The muscular damage pattern at IBM was characterized by tetraparesis predominantly proximal lower limbs and distal upper limbs. Serum creatine kinase levels in at least one of the measurements were elevated in all patients, but not exceeding 10 times normal. Immunosuppression was not effective in patients with IBM. The IBM histological findings included diversify dystrophic changes, endomysial inflammation, as well as the occurrence of rimmed vacuoles, in addition to high frequency of mitochondrial changes. Other characteristic muscle histological findings in IBM were increased lysosomal activity (overall increase in labeling for acid phosphatase), the presence of positive staining for beta-amyloid (intra-vacuolar by Congo red marking), increased muscle degradation (related to activation of LC3B, p-tau and p62 / SQSTM1) and muscle degeneration (marking for anti-phospo TDP-43 and ?-synuclein). Such changes have a high sensitivity and specificity. which makes these important complementary analyzes for accurate pathological diagnosis. We suggest that lowering the age of the onset of symptoms of greater than 45 years to older than 35 years would increase the diagnostic sensitivity for cases with IBM this study from 83% to 100%. With this study, it was possible to characterize clinically and histologically the patients with IBM in our centers, and provide evidence of the benefit of using degeneration and autophagy markers for diagnosis and for determining pathways or cellular systems involved in the pathogenesis of the disease

A miosite por corpos de inclusão (inclusion body myositis - IBM), na sua forma esporádica, é considerada a miopatia adquirida mais comum após os 50 anos de idade. Embora seja incluída no grupo das miopatias inflamatórias, estudos recentes mostram um processo particular de degeneração muscular caracterizado por deposição anormal de agregados de proteínas nas fibras musculares e funcionamento anormal dos principais sistemas de degradação proteica. O objetivo deste estudo foi o de avaliar os aspectos clínicos, histológicos e imunoistoquímicos de pacientes com IBM. Avaliamos 18 casos com diagnóstico de IBM de dois dos principais centros de doenças neuromusculares do Brasil (25 biópsias musculares). Na tentativa de diferenciar os casos de IBM das outras miopatias inflamatórias, determinamos o padrão de expressão tecidual da p-tau (p62), alfa-sinucleína e TDP-43. Também foi avaliada a função lisossomal através da reação da fosfatase ácida (marcação da atividade lisossomal global) e determinação da marcação para LC3B (marcador de autofagia). Foi observado que a IBM predominou no sexo masculino (61% dos casos), da cor branca, com início das manifestações clínicas ao redor dos 59 anos de idade e os sintomas mais frequentes foram fraqueza muscular, instabilidade postural com quedas da própria altura, disfagia e perda ponderal, podendo ainda apresentar dispneia. O diagnóstico demorou em média 7,4 anos após o início dos sintomas e frequentemente esteve associada às seguintes comorbidades: hipertensão arterial sistêmica, diabetes mellitus tipo 2, osteopenia / osteoporose, dislipidemia e hiperuricemia / gota. O padrão de comprometimento muscular na IBM foi caracterizado por tetraparesia de predomínio proximal em membros inferiores e distal em membros superiores. Os valores séricos da creatinofosfoquinase em pelo menos uma das medições foram elevados em todos os pacientes, porém sem ultrapassar 10 vezes o limite superior da normalidade. O uso de imunossupressão não se mostrou eficaz nos pacientes com IBM. Os achados histológicos na IBM incluíram alterações distróficas variáveis com a presença de inflamação endomisial, assim como a ocorrência de vacúolos marginados, além da elevada frequência de alterações mitocondriais. Outros achados histológicos musculares característicos na IBM foram o aumento da atividade lisossomal (aumento global da marcação para fosfatase ácida), a presença de marcação positiva para beta-amilóide (marcação intra-vacuolar pelo vermelho-Congo), o aumento na degradação muscular (relacionada com ativação de LC3B, p-tau, e p62/SQSTM1) e a degeneração muscular (marcação para anti-phospo TDP-43 e para ?-sinucleína). Tais alterações apresentaram alta sensibilidade e especificidade. Sugerimos que a redução do critério de idade do início dos sintomas de mais de 45 anos para mais de 35 anos aumentaria a sensibilidade diagnóstica para os casos com IBM deste estudo de 83% para 100%. Com este estudo, foi possível caracterizar clínica e histológicamente pacientes com IBM em nosso meio, e fornecer indícios do benefício do uso de marcadores de degeneração e autofagia para o diagnóstico e para a determinação de vias ou sistemas celulares envolvidos na patogênese da doença / Sporadic inclusion body myositis (sIBM) is considered the most common acquired myopathy affecting adults aged over 50 years. Although included in the group of inflammatory myopathies, recent studies show a particular process of muscle degeneration characterized by abnormal deposit of protein aggregates in muscle fibers and abnormal operation of the main protein degradation systems. The aim of this study was to evaluate the clinical, histological and immunohistochemical patients with IBM. We evaluated 18 cases with IBM diagnostic of two of the main centers of neuromuscular diseases in Brazil (25 muscle biopsies). In an attempt to differentiate the IBM cases of other inflammatory myopathies, we determined the pattern of tissue expression of p-tau (p62), alfa-synuclein and TDP-43. Also evaluated the lysosomal function by acid phosphatase reaction (marking global lysosomal activity) and determining the markup for LC3B (autophagy marker). It was observed that IBM was predominant in males (61% of cases), white colored, with onset of clinical manifestations around 59 years old and the most common symptoms are muscle weakness, postural instability with high falls, dysphagia and weight loss, and may also present dyspnea. The diagnosis took an average of 7.4 years after the onset of symptoms and was often associated with the following comorbidities: hypertension, type 2 diabetes mellitus, osteopenia / osteoporosis, dyslipidemia and hyperuricemia / gout. The muscular damage pattern at IBM was characterized by tetraparesis predominantly proximal lower limbs and distal upper limbs. Serum creatine kinase levels in at least one of the measurements were elevated in all patients, but not exceeding 10 times normal. Immunosuppression was not effective in patients with IBM. The IBM histological findings included diversify dystrophic changes, endomysial inflammation, as well as the occurrence of rimmed vacuoles, in addition to high frequency of mitochondrial changes. Other characteristic muscle histological findings in IBM were increased lysosomal activity (overall increase in labeling for acid phosphatase), the presence of positive staining for beta-amyloid (intra-vacuolar by Congo red marking), increased muscle degradation (related to activation of LC3B, p-tau and p62 / SQSTM1) and muscle degeneration (marking for anti-phospo TDP-43 and ?-synuclein). Such changes have a high sensitivity and specificity. which makes these important complementary analyzes for accurate pathological diagnosis. We suggest that lowering the age of the onset of symptoms of greater than 45 years to older than 35 years would increase the diagnostic sensitivity for cases with IBM this study from 83% to 100%. With this study, it was possible to characterize clinically and histologically the patients with IBM in our centers, and provide evidence of the benefit of using degeneration and autophagy markers for diagnosis and for determining pathways or cellular systems involved in the pathogenesis of the disease